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Where are all the missing cases of appendicitis, heart attacks, and gallbladder stones? They’re still sick, but not coming to the hospital for fear of SARS-COV-2 and COVID-19: Washington Post


puzzle by Gerd Altmann courtesy of

The Washington Post published a story on April 19 about patients missing from the normal retinue of emergency cases: those with the usual non-infectious illnesses such as appendicitis, heart attacks, strokes, cholecystitis, and gallbladder stones.  Mount Sinai cardiovascular surgeon John Puskas was quoted as saying, “Everybody is frightened to come to the ER [emergency room]”.  People who don’t come in with early signs of these acute emergency conditions are going to come later, when their symptoms have reached unbearable levels, and are going to be harder to help, with more complications or even death from untreated illness.

One anecdote, a patient with appendicitis in his twenties: he tried to “tough it out” with over-the-counter painkillers, until his appendix had ruptured and formed a large abscess in his belly.  He had to have open surgery (where a laparoscopy could successfully have removed an unruptured appendix) and a colostomy, meaning he was forced to spend days in the hospital.  He would have to return later to take down the colostomy to restore normal bowel functioning.  He had to take antibiotics for an extended period and could have died.  He was afraid to come to the hospital early, when his condition could have been quickly treated, because he was afraid of contracting the virus– even though, at his age, he might have had an asymptomatic infection or quickly recovered without any problems.

Evert Eriksson, trauma medical director at the Medical University of South Carolina, described this patient and said, “… 70 percent of the appendicitis on my service right now are late presentations. What happens when you present late with appendicitis is, we can’t operate on you safely.”  Yet his 700-bed hospital is only 60 percent full because most of their patients have been discharged to make room for an expected surge of coronavirus patients.

A report accepted April 7 as a pre-print in the Journal of the American College of Cardiology  (cited in the Washington Post article) documented a 38% reduction in patients admitted for percutaneous coronary artery revascularizations at nine major cardiac catheterization labs in the Northeast and Midwest in March 2020 as compared to the previous fourteen months.  These patients, all with acute myocardial infarctions (heart attacks) with ST segment elevation (a sign of complete blockage of a major coronary artery to the heart), simply were not seen.  Some of them would have died without this treatment; the rest suffered severe heart damage and were left with weakened or reduced heart function.  This happened at a time of stress when heart attacks would have been expected to increase rather than decrease.

From the Washington Post article:

A Gallup online poll taken March 28 to April 2 asked people with different conditions how concerned they would be about exposure to the coronavirus if they needed “medical treatment right now” at a hospital or doctor’s office. Eighty-six percent of people with heart disease said they would be either “very concerned” or “moderately concerned.” Among people with high blood pressure, the figure was 83 percent.

One major stroke center found a more than 60 percent reduction in referral calls from hospital ERs about possible stroke patients and a more than 50 percent reduction in patient phone calls.  It seems that patients with mild or moderate stroke symptoms are simply not calling in for help.

Some conditions are less common because of the almost universal “stay at home” orders blanketing the country.  There has been a steep drop in car crashes, for example.  There has not been a drop in domestic violence incidents.

Some heart attacks may be prevented by people not going to work and not exerting themselves at home.  Others may be prevented by not eating high-fat restaurant meals and the drop in air pollution (and air pollution, especially particulates, does bring on heart attacks).  Some patients with heart attacks may never make it to the hospital because emergency medical protocols have changed.  Those who suffer cardiac arrest and do not have return of spontaneous heart action (and circulation) after resuscitation efforts are not being taken to the ER, but are declared dead in the field.

Finally, some patients with COVID-19 may have double diagnoses: both new virus disease and heart attacks at the same time.  Only time and thorough review of all findings will tell us where all the emergency patients have gone.

Deep uncertainty about the new virus and its effects on patients with pre-existing conditions has made the job of treating all patients during this pandemic much harder.  We already know that conditions like diabetes, high blood pressure, and heart disease make infections with the new virus worse.  What we don’t know is why other factors, many of which are more prevalent in elderly patients, make recovering from an infection so much harder.  We don’t know what other genetic or social conditions are doing to make the infection and death rates so much higher in African-American and Caribbean-American patients; we just know that things are much harder for black people.






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